I have noticed a few “Letters to the Editor” and social media comments lately misrepresenting the “York review” on fluoridation so looked into the background of some of these claims.
The “York review” (McDonagh, et al., 2000) is one of the earliest authoritative and comprehensive reviews of the scientific literature related to fluoridation and resulted from a request by the UK Department of Health for:
“a systematic review of the evidence for the safety and effectiveness of water fluoridation based on the currently available evidence from population-based studies.”
As a systematic review it is a valuable resource for decision-makers so this review – together with later and more comprehensive reviews – is usually accepted as one of the most reliable sources of evidence for local bodies considering fluoridation issues. However, this very authority leads to its misrepresentation by activists.
We are used to activists misrepresenting the evidence contained in such reviews, but I want to comment on the way anti-fluoride propagandists attempt to present the review authors as supporting anti-fluoride positions. In particular, the way they use quotes from anti-fluoride people who have some tenuous connection to the review. These quotes are presented as authoritative, consistent with the reviews findings and with the implications the people quoted were authors or members of the York Fluoride Systematic Review Team – when they were not.
Review Team & Advisory Panel
The York Fluoride Systematic Review Team were the authors of the report. These authors and affiliation are:
- Jos Kleijnen, NHS Centre for Reviews and Dissemination, York, UK
- Marian McDonagh, NHS Centre for Reviews and Dissemination, York, UK
- Kate Misso, NHS Centre for Reviews and Dissemination, York, UK
- Penny Whiting, NHS Centre for Reviews and Dissemination, York, UK
- Paul Wilson, NHS Centre for Reviews and Dissemination, York, UK
- Ivor Chestnutt, Dental Public Health Unit, Cardiff, Wales, UK
- Jan Cooper, Dental School, University of Wales College of Medicine, Cardiff, Wales, UK
- Elizabeth Treasure, Dental School, University of Wales College of
Medicine, Cardiff, Wales, UK
However, an advisory board was also appointed. This included representatives from “both sides of the fluoridation debate” as well as including neutral people. According to Richards et al., (2002):
“Although the advisory panel and review team agreed the results of the review, agreement was not reached about the conclusions or, more importantly, the implications of the review.”
Hardly surprising given the differing views on the issue. This article adds:
“Parties on each side of the controversy were reluctant to abandon their previous positions and endorse the review result whole-heartedly.”
The Systematic Review Advisory Panel members were:
- Chair: Trevor Sheldon, York Health Policy Group, University of York, York, UK
- Earl Baldwin of Bewdley, House of Lords, London, UK
- Iain Chalmers, UK Cochrane Centre, Oxford, UK
- Sheila Gibson, Glasgow Homeopathic Hospital, Glasgow, Scotland, UK
- Sarah Gorin, Help for Health Trust, Winchester, UK
- Mike Lennon, Chairman of the British Fluoridation Society, Department of Clinical Dental Sciences, University of
Liverpool School of Dentistry, Liverpool, UK - Peter Mansfield, Director of Templegarth Trust, Louth, UK
- John Murray, Dean of Dentistry, University of Newcastle, Newcastle
upon Tyne, UK - Jerry Read, Department of Health, London, UK
- Derek Richards, Centre for Evidence-Based Dentistry, Oxford, UK
- George Davey Smith, Department of Social Medicine, University of Bristol, Bristol, UK
- Pamela Taylor, Water UK, London, UK
Readers will see the mixed nature of this group so won’t be surprised there were fixed views which prevented their endorsement of the review findings and conclusions.
Opportunist quoting of minority views
Anti-fluoridation propagandists have made much of quotes from 2 advisory panel members – people who were not authors of the review and could not represent the review itself.
Out of context quote from anti-fluoride site No Fluoride.
Professor Trevor Sheldon has made a statement emphasising the provisional nature of the reviews findings, commenting on the poor quality of much of the research of health aspects and stressing the limitations of the review and need for further work. His statement recognised that fluoridation is effective at reducing tooth decay The quality of research on health effects has also improved in recent years. However, anti-fluoride people use the quote in attempts to undermine research showing the efficacy of fluoridation and the lack of harmful effects. It is more correct to say, as Newton et al., (2015) did recently:
“In general, the literature suggesting adverse health effects of fluoridation is characterised by poor-quality studies that do not adequately adjust for potential confounding variables.”
Please note, Sheldon was a member of the Advisory panel and not an author of the review.
Another quote which has been rehashed recently by activists is from Advisory panel member Peter Mansfield:
“No physician in his right senses would prescribe for a person he has never met, whose medical history he does not know, a substance which is intended to create bodily change, with the advice, ‘Take as much as you like, but you will take it for the rest of your life because some children suffer from tooth decay.’”
Users of the quote imply he was an author of the review report – for example “Mansfield took part in the University of York (in York, England) review of public water fluoridation in 2000.” He did not. He was merely a member of the Advisory Panel representing the views of anti-fluoridationists. Have a search for him on the internet (he is the Director of Templegarth Trust, Louth, UK) to get a picture of his alternative health views.
Conclusions
In their article about the York Review Richards et al., (2002) indicate that this early review identified problems with review processes and existing knowledge which future work would overcome:
“Future research can be more efficient and sharply focused as a result of open reviews of this kind. A consensus on future research priorities was one result of this review. The eventual findings of future work are more likely to be debated rationally and achieve wide consensus than if the review had not taken place.”
Anti-fluoride propagandists are simply taking advantage of those early issues, and dishonestly implying that they out-of-context quotes they use were made by authors of the York review when they weren’t.
References
McDonagh, M. S., Whiting, P. F., Wilson, P. M., Sutton, a J., Chestnutt, I., Cooper, J., … Kleijnen, J. (2000). Systematic review of water fluoridation. BMJ (Clinical Research Ed.), 321(7265), 855–9.
McDonagh, M., Whiting, P., Bradley, M., Cooper, J., Sutton, A., & Chestnutt, I. (2000). A Systematic Review of Public Water Fluoridation. 258 pp. Full report.
Newton, J. N., Young, N., Verne, J., & Morris, J. (2015). Water fluoridation and hypothyroidism: results of this study need much more cautious interpretation. Journal of Epidemiology and Community Health, 69(7), 617–8. http://doi.org/10.1136/jech-2015-205917
Richards, D., Mansfield, P., & Kleijnen, J. (2002). Systematic review in scientific controversy: the example of water fluoridation, an open access review. Evidence-Based Dentistry, 3, 32–34.
Open Parachute 
Hi Ken
I note your references only give the 5 page BMJ summary of the 258 page York review (linked to toward the top of the blog… they are quite different beasts…
Those members of teh advisory board WERE involved in the study… albeit in an advisory capacity. I have had personal communications with Iain Chalmers and Trevor Sheldon over the years… Despite the high level of evidence you claim exists, including the infamous York Report, Iain remains a agnostic… as he’s said to me, “show me the evidence.” He’s not convinced… Hi personal view is thee is a lot of faith involved… on both sides… He, the father of evidence-based medicine, is not convinced that fluoridation is an effective public health initiative.
Ron
The review team gratefully acknowledges the invaluable contributions of the members of the Advisory Board: The Earl Baldwin of Bewdley, House of Lords; Sir Iain Chalmers, UK Cochrane Centre; Dr. Sheila Gibson, Glasgow Homeopathic Hospital; Ms. Sarah Gorin, Help for Health Trust; Professor MA Lennon, Department of Clinical Dental Sciences, University of Liverpool School of Dentistry, Chairman of the British Fluoridation Society; Dr. Peter Mansfield, Director of Templegarth Trust; Professor JJ Murray, Dean of Dentistry, University of Newcastle; Mr. Jerry Read, Department of Health; Dr. Derek Richards, Centre for Evidence-Based Dentistry; Professor George Davey Smith, Department of Social Medicine, University of Bristol; Ms. Pamela Taylor, Water UK. Special thanks to Professor Trevor Sheldon, Department of Health Studies, University of York, who chaired the Advisory Board.
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Sorry, Ron – I had thought I gave a link to the full report in the reference list. I have added it now so readers can choose which version to read.
The panel was not involved in writing the report and did not completely accept its findings or conclusions. The review team met with the panel only 3 times – according to Richards et al. (2002) (authored by 2 members of the panel and one member of the review team):
Given the lack of endorsement by of the review by the panel and the fixed views of some of its members it is dishonest to imply individual statements like Mansfield’s represent the review in any way. They are personal views only.
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I see the panel included Sheila Gibson, Glasgow Homeopathic Hospital, Glasgow, Scotland, UK
(eyes pop)
Homeopathic hospitals!
I wonder if all the water in their medicine cabinets remembers if it once had fluoride in it.
Something for Soundhill to wonder and postulate about.
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Thank you, Ken. This is excellent information. The use of out-of-context quotes and other information, usually without proper citation to the primary source, is one of the more reprehensible tactics of antifluoridationists, and one of the most frequently utilized by these activists.
Steven D. Slott, DDS
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These reviews have one thing in common in that, while the first is related to topical fluoride and the second to CWF, both highlight the need for more high quality research. That is also a notable concern expressed by CHER, the WHO and other reviews such as the Fort Collins one, to mention but a few.
As far as I can ascertain there has been no high quality research conducted or if it has been done the health authorities are keeping it well hidden because every time verification evidence is asked for all that is produced are the reviews that ask for high quality research to be done. That is not science, that is obfuscation.
The following is taken verbatim from a document produced for the Waikato District Health Board by NZ Child and Youth Epidemiology Service November 2008.
1. Marinho V, Higgins J, Logan S, Sheiham A. Topical Fluoride (Toothpastes, Mouth rinses, Gels Or Varnishes) For Preventing Dental Caries In Children And Adolescents. Cochrane Database of Systematic Reviews 2003, Issue 4.
The use of fluoride toothpastes, mouth rinses, gels or varnishes reduces tooth decay in children and adolescents. This review of trials found that children aged 5-16 years who applied fluoride in the form of toothpastes, mouth rinses, gels or varnishes had fewer decayed, missing and filled teeth regardless of whether their drinking water was fluoridated. Supervised use of self applied fluoride increases the benefit.
Fluoride varnishes may have a greater effect but [more high quality research is needed] to assess the magnitude of the effect, and whether they have adverse effects. There are a number of other Cochrane reviews which compare the efficacy of fluoride mouthwashes, gels, vanish and toothpastes
2. Centre for Reviews and Dissemination. Systematic Review of the Efficacy and Safety of the Fluoridation
of Drinking Water. CRD Report 18. York: University of York. 2000.
http://www.york.ac.uk/inst/crd/projects/fluoridation.htm
This review found that although a large number of studies had been conducted in the past 50 years, there is a lack of reliable, good quality evidence in the fluoridation literature world-wide. The available evidence
suggests that water fluoridation reduces caries prevalence but the degree to which it does so is not clear from the data (results of individual studies ranged from a substantial reduction to a slight increase in prevalence). This beneficial effect may also come at the expense of likely increases in the prevalence of dental fluorosis (mottled teeth). [The research evidence is of insufficient quality to allow confident statements about other potential harms or whether there is any impact on social inequalities].
Obviously someone needs to inform the WDHB that they should stop disseminating information that raises more questions about fluoridation than it does in providing sensible answers.
Interesting to note that our DHBs chief spin doctor and apologist for fluoridation was recently asked to reapply for her position and chose instead to move on or was she pushed?
Have a great day!
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Trev, do you have problems of a short attention span? 🙂
Did you not notice this post effectively dismantles the last comment of yours where you imply that the person you quoted was an author of the York review when they were, in fact, not.
Isn’t that dishonest of you?
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Trevor dishonest? Surely you jest. He is every bit as honest and truthful as are the vast majority of antifluoridationists……..
Steven D. Slott, DDS
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So at last there is a glimmer of intelligence from Steven in his admission that some anti-fluoridationists are honest and truthful, perhaps he could name them so we can take a closer look at their postings. I suggest he should look a little closer to home to see who is dishonest and untruthful.
Ken – I am surprised at your rather shallow response to my post which was simply highlighting the call in the York Review [and many other reviews] of the need for high quality research to settle the on-going debate around fluoridation. It matters not a jot what implications you draw from my comments nor does the inference that I am dishonest have any weight or bearing on the issue.
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Trev, I realise you are embarrassed at being called out with your dishonest implication that your quote came from the authors of the York report. But an adult would front up and admit the implication was unwarranted – not attempt diversions.
As for you “discovery” that scientists call for more research – that just demonstrates an opportunist naivety. Of course scientists call for more research. The cynical might suggest it’s a way of keeping us in a job. Those who understand the nature of human knowledge recognise that our understanding are always open to improvement – even where our knowledge is adequate for decisions on issues like fluoridation.
Consider for example – it is reasonable to judge more high quality research is required for a better understanding of other water treatment processes like chemical sedimentation and flocculation, and about chlorination. However, our current understanding is sufficient for such social measures to be used with a very reasonable degree of confidence.
Also consider, the references to poor quality research describes the very research people like you are attempting g to use to discredit fluoridation. The fact that objective reviews find that such research is of so poor quality they do not justify your claims is what at you should be concentrating on.
Your claims do not justify any action until there is sufficiently high quality research to justify your assertions,
>
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I was quite shocked to read that.
“Professor Trevor Sheldon has made a statement emphasising the provisional nature of the reviews findings, commenting on the poor quality of much of the research of health aspects and stressing the limitations of the review and need for further work. His statement recognised that fluoridation is effective at reducing tooth decay The quality of research on health effects has also improved in recent years. However, anti-fluoride people use the quote in attempts to undermine research showing the efficacy of fluoridation and the lack of harmful ”
He didn’t mention “anti-fluoride people”.
Why did you incorrectly summarise like that? His criticism was about all parties including Ministries of health etc. including people like you. Clearly you did not get the message.
This is what he said.
“We are concerned about the continuing misinterpretations of the evidence and think it is important that decision makers are aware of what the review really found. As such, we urge interested parties to read the review conclusions in full.
We were unable to discover any reliable good-quality evidence in the fluoridation literature world-wide.
What evidence we found suggested that water fluoridation was likely to have a beneficial effect, but that the range could be anywhere from a substantial benefit to a slight disbenefit to children’s teeth.
This beneficial effect comes at the expense of an increase in the prevalence of fluorosis (mottled teeth). The quality of this evidence was poor.
An association with water fluoride and other adverse effects such as cancer, bone fracture and Down’s syndrome was not found. However, we felt that not enough was known because the quality of the evidence was poor.
The evidence about reducing inequalities in dental health was of poor quality, contradictory and unreliable.
Since the report was published in October 2000 there has been no other scientifically defensible review that would alter the findings of the York review. As emphasised in the report, only high-quality studies can fill in the gaps in knowledge about these and other aspects of fluoridation. Recourse to other evidence of a similar or lower level than that included in the York review, no matter how copious, cannot do this.
”
Imagine a review that includes people with different perspectives. How terrible to have a group that can keep each other honest.
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